Realistic Medicine and Realistic Transfusion · 2019. 12. 11. · Review and standardise transfusion training at induction sessions for Portering and Phlebotomy staff groups. Review

Realistic Medicine and Realistic Transfusion

Danny McGee

Senior Practitioner

Scottish National Blood Transfusion Service

Transfusion Team

I have no potential conflicts of interest with this presentation

5.4 million people

14 Territorial Health Boards

8 support Boards (including NSS)

29 Blood banks

189,894 blood components transfused in 2018

142,670 Red Cells,

23,881 Platelets,

20,208 FFP,

3135 Cryoprecipitate

Chief Medical Officer for Scotland, Dr Catherine Calderwood:

Realistic Medicine launched in 2015

2014 - 2015

https://www.realisticmedicine.scot/

•Realism in Healthcare mindful over treating patients

•Sharing decision making and informing consent

•Management of Clinical Risk

•Changing our practice to support Quality Improvement

•Using Data to support decisions and learning

•Taking time to talk with colleagues

•Creating a multidisciplinary team culture



Realising Realistic Medicine

2015 - 2016


Produced in response to feedback form 2014-2015 report

Applicability was not confined to Doctors and RM message was spreading beyond Scotland borders and across the world.

Engaging with the people we are caring for and the wider public

Strategies to enhance Shared Decision making improve peoples knowledge about their condition and treatment options.

Their involvement and satisfaction with their care

Improves care givers communication with people that they are caring for

A Scottish Atlas of variation would be published and training in understanding unwarranted variation

Embedding RM principles into medical education



Practising Realistic Medicine

2015 - 2016

https://www.realisticmedicine.scot/2016 - 2017

Responding to challenges regarding lack of time to discuss peoples priorities, ensure that they have all the information needed to make an informed shared decision

Support and accelerate the transition from a discussion about RM to their practical application

Learning from good communicators

Making shared decision making the norm

Valuing our workforce – engaged staff feel their personal activity is more connected to the purpose of their team and the organisation



Personalising Medicine

2015 - 2016

https://www.realisticmedicine.scot/2017 - 2018

Adopting a what matters to you conversation into practice

Strengthening the relationship between healthcare professionals and patients

Reducing harm and waste

Finding time to give to patients

Engaged patients

Supported workforce

Compassionate leaders

Culture of stewardship



Realistic Medicine launched in 2015

2014 - 2015 2016 - 20172015 - 2016 2017 - 2018



20 Realistic Medicine Clinical Leads appointed across NHS Scotland to:

Embed Realistic Medicine principles and practice within their boards and regions

Provide leadership and advice to colleagues on the key domains of Realistic Medicine

Champion Realistic Medicine locally, creating the culture and conditions for it to thrive



“Realistic Medicine puts the person receiving healthcare at the centre of decision-making and creates a personalised approach to their care

The aim of reducing harm and waste and simplifying care while managing risks and innovating to improve are essential to a well-functioning NHS”

https://www.gov.scot/publications/summary-practising-realistic-medicine/


SNBTS Transfusion

Team 2019

Better Blood Transfusion2003

2016

Orkney, Shetland, Western Isles, Highland, Grampian, Tayside

Fife, Lothian,Borders

West 2

West 1

Greater Glasgow and Clyde, GJNH

Forth Valley, Lanarkshire, Dumfries and Galloway,Ayrshire and Arran

North

East

CENTRAL PROGRAMME TEAM

Jack Copland Centre

SNBTS Transfusion Team

Regional Model

SNBTS Transfusion

Team 2019

Better Blood Transfusion2003

2016

Our Purpose

To continuously improve the safety, effectiveness and appropriate use of blood.

Could we develop a work plan that aligned with Realistic Medicine?

In the context of transfusion how could the Transfusion Team

Promote shared decision making?

Support clinical staff in building a personalised approach

Reduce harm and waste

Reduce unwarranted variation in practice

Manage risk

Continue to be innovative

Within the limits of our available resources

Education National PolicyPatient Blood Management

Information & Quality

Improvement Haemovigilance

SNBTS Transfusion Team

SNBTS Transfusion Team Pillars & Working Groups

September 2019 October2019

November 2019 December 2019 January 2020

February2020

March 2020

Ensure completion of 'implementation phase' of the Better Blood Transfusion review

Produce a national training matrix for mandatory LBT transfusion training for all NHSScotland staff groups.

Review and standardise transfusion training at induction sessions for Portering and Phlebotomy staff groups.

Review and update Training and Assessment Accreditation Programme (TAAP)

Develop a 'once for Scotland' approach to undergraduate nursing transfusion education aligned to the NMC proficiency standards and adopted by every HEI in Scotland.

Design a new National Transfusion Record

Identify and prioritise transfusion related policies that can be developed at a National level

Establish a baseline of Single Unit Transfusion practice across NHSScotland

Link ICS Data to Transfusion Data

Support the identification and management of pre-operative anaemia

Establish a baseline of Tranexamic Acid practice through information gathering

Produce a rolling 2-year National plan for NCA and SNBTS TT audits. Complete IDA auditand promote NCA Medical Use of Blood audit.

Ensure SNBTS TT staff are competent and confident to promote the use of the Blood Bank Dashboard to support clinical blood use.

Improve use of data to support O-neg use.

Establish a minimum level of QI training to improve Quality Improvement capability of SNBTS TT staff

Haemovigilance ‘Toolkit’ development

National data and trending

Review staff perceptions of impact (01/10) 01/03

Review impact with NHS Boards ( 01/10) 01/03

Progress to date

Final document completed and signed off 31/10

New training commences 02/12

Updated course launched 30/11

lecture presentation complete 30/9

New record launches 03/02

Transfusion record launched 02/12

Service evaluation report 31/03

Final coding measurement 26/03

Disseminate audit report 31/10

NCA data collection closes 31/12

Staff survey closes 04/10

SNBTS TT Report 30/11

All staff completed standard 31/03

Scoping meeting 29/09

Supporting resources complete 30/09

Review feedback received

Projects managed by SNBTS Transfusion Team 2019/20

TBscoped

TBScoped C

ABO serology workbook complete 28/02



Transfusion Record Review

Transfusion Practitioners submitted the current transfusion record from each all territorial health boards (n=14) and special health boards where transfusion takes place (n=1)

Recorded criteria were noted and compared (a) against BSH guidelines b) against the recommendations from SHOT regarding TACO. Many Documents contained the majority of desirable fields however none achieved 100% compliance.

All but one document contained a pre transfusion checklist. None of the documents contained a checklist for TACO although one did use the SHOT TACO graphic.

New template has been developed that meets all desirable fields allowing the health boards to achieve 100% compliance with BSH guidelines and SHOT recommendations.

Currently reaching the end of pilot phase

All health boards will be encouraged to adopt the new template

Reducing waste through repetition Promoting and improving recording of consent Managing risk through introducing pre transfusion checklist &TACO checklist.

Transfusion Record Review

CONSENT

Realistic Medicine is about ensuring decisions are made in partnership with people, helping them to make the choices about their treatment and care that are best for them as individuals.

The Montgomery ruling on consent is about providing information transparently – being open and honest in our discussions with individuals about the risks and benefits of different courses of action is integral to best practice.

Our patient and donor information leaflets are being updated to include Duty of Candour statements

The importance of consent for blood transfusion is being taught to all healthcare professionals including nursing and medical students

...is a multidisciplinary, evidence-based

approach to optimising the care of patients

who might need blood transfusion

...puts the patient at the heart of decisions

made about blood transfusion to ensure they receive the best

treatment

...represents an international initiative

in best practice for transfusion medicine

... and avoidable, inappropriate use of

blood and blood components is reduced

•Optimising red cell mass

•Minimising Blood Loss, appropriate blood sparing strategies

•Tolerating Anaemia, personalised transfusion triggers and targets

•Single Unit transfusion

Patient Blood Management

Adverse event and Reaction Management

Currently being rolled out

Practice to be reviewed once embedded.

STED

ACaDMe

AfB

Hospital laboratory information

systems

Stock Position

Reports

Clinical Context

Reports

Stock Management

ReportsTransfusion

Activity Reports

Input

Processing

Output

Routine, daily national data on the supply & use 2009+

NHSS hospital episode data: clinical context

Monthly linkage: date & clinical priority

Turning Data into Information

Tableau Server

Supporting local hospital blood banks and clinical teams with management ofblood component inventory, clinical incidents and staff training.

8 viewsInteractive

visualisation

Blood Bank Dashboard

BBT Audit

Complete IDA audit Produce a rolling plan for BBT audits

NCA Audit

Produce a national plan for participation in NCA audits Promote & support NCA Medical Use of Blood audit

Staff Training

Dashboard Quality ImprovementProject ManagementMRC GDPR

Audit and Quality Improvement

13% of blood

donors

14.6% of blood

issues

9.3% of patients

O negative red cells are used as safety stock to issue in case of an emergency. Fortunately most of the emergencies don’t happen!

This precious blood is at risk of being discarded untransfused unless we do something about it

O D negative blood

Blood Bank Clinical Arena

SNBTS Transfusion Team Influence

Number of red cells booked in

11569

11601

10691

11365

11070

10600

11621

10495

10700

10461

10721

9932

9000

9500

10000

10500

11000

11500

12000

Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19

Red Cells Booked in

Median 10710.5

Dec: Letter to all Boards

Jan: TPs involved

Feb:First HTT action plans submitted

Mar:Toolkit and survey for HTTs developed

Apr:First Survey response

May:Second Survey response

June:Third Survey response

Number of OD Neg red cells booked in

16901722

1581

1627

15651510

1699

1400

1445

1598

1436

1343

0

200

400

600

800

1000

1200

1400

1600

1800

2000


OD Neg Red Cells Booked in Median 1573


Jan: TPs involved




May:Second Survey response June:

Third Survey response

Percentage of OD Neg red cells booked in

14.6%

14.8% 14.8%

14.3%

14.1%

14.2%

14.6%

13.3%

13.5%

15.3%

13.4%13.5%

12.0%

12.5%

13.0%

13.5%

14.0%

14.5%

15.0%

15.5%


%OD Neg Red Cells Booked in

Median 1573

KPI 13.5%


Jan: TPs involved




May:Second Survey response

June:Third Survey response

0

2000

4000

6000

8000

10000

12000

14000


Axi

s Ti

tle


Red Cells Booked in 11569 11601 10691 11365 11070 10600 11621 10495 10700 10461 10721 9932

OD Neg Red Cells Booked in 1690 1722 1581 1627 1565 1510 1699 1400 1445 1598 1436 1343

Red cells total and OD neg red cells by month

Equip staff with relevant skills

Provide time and space to encourage staff to be innovative

New team focus

New challenges

New ideas

All staff actively engaged in activities to monitor and improve quality and outcomes in transfusion

Innovate !

The Realistic Medicine vision is by 2025, everyone who provides healthcare in Scotland will demonstrate their professionalism through the approaches, behaviours and attitudes of Realistic Medicine.

Through our Realistic Transfusion Campaign we can...

Help to build a personalised approach to transfusion

Facilitate involving the patient in the decision to transfuse

Identify and address unwarranted variation and waste

Support the reduction of harm and manage risk

Put Realistic Medicine into practice

Set the vision and future direction of SNBTS Transfusion Team


Shared decision-making

Consent & patient information

Patient blood management

Personalised transfusion triggers & targets, blood

sparing strategies, optimising Hb,

HaemovigilanceImplement SHOT

recommendationsSupport national reporting and incident investigation

Dashboard and dataTurning data into

informationUnderstand variation,

reduce waste, audit. And QI

Education and Training

Avoid delays & over-transfusion, knowledge

transfer

Innovate!

New Team, New Culture New Ideas

REALISTIC TRANSFUSION


• Dr Megan Rowley SNBTS Transfusion Team Clinical Lead

• Dr Katherine Forrester, Transfusion Researcher, SNBTS Transfusion Team

• Dr Alex Stirling, Clinical Lead Realistic Medicine

• Diane Sydney, Senior Nurse SNBTS Transfusion Team

• Dr Karen Bailie, previous BBT Clinical Lead

• SNBTS Transfusion Team staff across Scotland

• Blood banks

• NHSS Clinical teams

Acknowledgements

Thank youDanny McGee

Senior Practitioner

Scottish National Blood Transfusion Service

Transfusion Team